High PSA, but MRI is negative. Biopsy or Not?

@handera, I totally agree. Its really easy to forget about living your life because the prostate cancer roller coaster can be all consuming. And it's also interesting the new things you can discover when you start making some changes. For me, blueberries, pomegranates, running and non alcoholic pints of Guinness have been nice surprises! I used to drink a fair bit of red wine but now on occasion I have a nice glass of Pino Grigio with my broccoli sprouts. 🙂

@capatov
If you have come off of the adt, don’t be discouraged if PSA rises. .04 is VERY low.

Get a biopsy. The statistics don't lie. If you have cancer cells now is the time to get rid of them before they spread outside the prostate. The biopsy is the gold standard.

@lookin4answers
My MRI did not reveal lesions or tumors just suspicious areas. I had MRI/Fusion biopsies and confirmed had PC with Gleason Score.

I did not hesitate to have biopsies and wanted to know if PC. PC when caught early is at the cellular level and hard to see on a MRI if still a cellular level. So the biopsies would reveal if cancer or not.

If you ever look at explanation of Decipher score you can see is subjective. Urologist or pathologist looks at normal looking cells compared to abnormal looking cells and grades them with Gleason score. Without a Gleason score or other method to determine if have PC not going to know. A MRI is a wonderful tool but does not look at tissues like a biopsy. A Decipher test is going to look at your biopsies genetically and gives a far better diagnosis of risk level than a Gleason score. Information comes from Mayo Jacksonville urologist, Mayo R/O, UFHPTI R/O, Mayo PCP.

If you have biopsy done transperineally with anesthesia you will have not pain, no discomfort, and no anxiety/stress if done transrectal and being awake. I can pass that on as my experience not talking about others.

Transperineally removes the increased infection rate that transrectal brings. Of course with any surgery there is always a chance of infection and or complications but not the type of infection risk if biopsy is done through rectum.

I'd think about getting a second opinion on the MRI that has already been done.

I couldn't find the reference just now, but when my urologist recommended an MRI, I asked that it be performed and read by the nearest NCI designated cancer center as opposed to his preferred community imaging center. I felt I would have more confidence in what the report said, if it was done by someone in a high volume center who does a lot more prostate MRIs than anyone in a community imaging center.

My urologist didn't appreciate my questioning the quality of his usual place, but he went along with it once I gave him several references to papers that found a wide variation even among the top flight cancer centers. One paper I remember found a wide variation in PiRads scores depending which MRI report person did the interpretation of the same images, at the same institution, i.e. Stanford. A national organization is or has just recently set up a plan to certify imaging centers as competent in reading prostate MRIs. Sorry I can't give exact references, no time at the moment.

@climateguy
Now that is taking your medical care the way you should!

Sometimes even if uncomfortable discussion you must take an active role in your medical and mental health care.

Getting second opinion was something my Mayo PCP recommended even though my first diagnosis and treatment plan was at Mayo.

I am 67 and had 7.1 PSA but negative MRI. My urologist did a free PSA blood test that showed up to 50% chance of PC in my gland. He suggested and we did a biopsy which showed two positive cores (out of 12) with one low grade 3+4 = 7 and the other 4+3 = 7 intermediate grade. PSMA PET showed PC confined to gland.

I opted for a three pronged approach to treatment - 5 weeks IMRT + one HDR "boost" procedure + 6 months Orgovyx ADT. Going back for follow up 6 month post treatment PSA in January. Hoping PSA remains close to 0

I would recommend getting the biopsy...early detection is key to long term survival with PC

@capatov My case is somewhat similar to yours, except more advanced. (5 cores out of 12, seminal vesicles are now also involved). If you had chosen to put your biopsy off for another year, perhaps you'd be in my boat.

I was so concerned early on to avoid a biopsy in case it wasn't necessary, but now that I've been sentenced to 2 years of ADT, and 5 weeks of EBRT, I see that having a biopsy seems trivial.

Urologists seem a bit trigger happy when recommending a biopsy, but they have a very good idea of how serious things can get if you don't find out what's happening in time.

Part of my hesitation was the older idea, that was somewhat set in stone in 2012 by the US Preventative Services Task Force, that no men should be routinely screened with PSA testing. The problem then was way too many men were being tortured with biopsies and treatments with not much to show for it in terms of extended life span for the group. The solution, no testing, is now very clearly seen to have been mistaken. The current emphasis on active surveillance for lower grade cancers that are found on biopsy seems to be a far better idea.

It took me a while to actually look into this impression that I had, i.e. PSA tests shouldn't even be done, to where I realized things had changed since 2012. I did get a repeat PSA test to make sure the results were consistent, then I agreed to a biopsy - months after when I should have had one.

I had a transperineal biopsy in order to reduce the risk of infection that can happen more often with the alternative, i.e. transrectal biopsy. I felt the effects for weeks afterward, but the effects were hardly problematic. There were dark blood stains left by my ejaculate for months afterward but this eventually went away.

@climateguy - I appreciate your situation and hesitation to get the biopsy. I live in ATL and my son is an anesthesiologist that works at Emory St Johns hospital with may of the best Emory Winship Cancer Institute MDs. He connected me to what he felt was the top urologist/surgeon and Radiation Oncologist.

I too inquired about transperineal vs. transrectal biopsies. I had seen some research that transperineal had lower infection rates. But Emory MDs said latest research shows they are almost equal with less than 1 % infection rate. Granted, when you do get an infection it is often very serious.

I was very lucky that after my transrectal biopsy and subsequent 5 weeks IMRT + high dose brachytherapy...I had zero pain, bleeding or other issues. I consider myself very fortunate/blessed in this regard.

I will keep you in my thoughts and prayers!

Good luck to you

another issue with transrectal biopsy is antibiotic resistance. Far more antibiotic is used with transrectal. In the U.K. it transrectal biopsy is not done anymore.